Several surveys have identified inadequacies in training, support, and follow-up of patients receiving HETF and HPN. Specific problems include lack of written instructions about how to manage simple problems that may arise during feeding, lack of telephone contacts for use in emergency, lack of confidence, and inadequacy of equipment for home use. Such surveys have also highlighted the importance of a multidisciplinary approach and the need to undertake home visits to assess the status of severely disabled patients who cannot easily attend a hospital. Pressure on hospital beds has meant that some patients are discharged home before they have been adequately trained, and the care of such patients is sometimes passed on to other health care workers who have little experience of home nutritional support. Since HPN is relatively uncommon in the population, general practitioners may have never encountered patients on this form of therapy and are therefore poorly equipted to manage them. Patients' needs may change during the course of their treatment; therefore, there is a need to establish an organisational infrastructure for continuity of care for HETF and HPN over time and from one health care setting to another. Many hospitals do not have a nutrition team or policies that embrace the needs of people receiving artificial nutrition at home.
A series of guidelines for the management of artificial nutrition in the community have been developed by BAPEN (Tables 3 and 4). The guidelines cover aspects of training prior to discharge from hospital (although training can take place at home) and the support required from trained specialist staff once the patient is at home. A national and local organizational structure for delivering the support would aid the process.
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